Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

341. Surgical Treatment of Vasospastic and Vaso-occlusive Diseases of the Hand

Scott L. Hansen, Neil F. Jones, and Charles K. Lee

DEFINITION

images Vasospastic and vaso-occlusive diseases of the hands include a wide range of disorders that cause decreased or limited blood flow to the digits, resulting in chronic ulcerations and even loss of digits.

images Vasospastic disorders result from constriction of the microvasculature, resulting in decreased blood flow.

images The most common vasospastic disorder is Raynaud syndrome.

images Raynaud syndrome may also have an obstructive component.

images Vaso-occlusive disorders produce disruption of blood flow due to a reduction in cross-sectional area of the vessel lumen.

ANATOMY

images The right common carotid artery and right subclavian artery originate from the brachiocephalic trunk, whereas the left subclavian artery branches directly from the aorta.

images The subclavian artery becomes the axillary artery at the distal edge of the first rib and ends at the distal edge of the teres major tendon.

images The brachial artery is a continuation of the axillary artery, beginning at the distal margin of the teres major.

images The hand is supplied by the radial and ulnar arteries, which originate from the brachial artery at the level of the antecubital fossa.

images The radial artery becomes the deep palmar arch; the ulnar artery becomes the superficial palmar arch (FIG 1).

images

FIG 1  Vascular anatomy of the hand.

images The superficial palmar arch is the major arterial inflow to the fingers on the ulnar aspect of the hand, whereas the deep palmar arch supplies blood to the digits on the radial aspect of the hand.

images The superficial palmar arch lies more distal in the palm than the deep palmar arch.

images In about 80% of patients, the deep and superficial palmar arches are in continuity, a configuration described as a complete palmar arch.3

images In a small subset of patients, a persistent median artery also can contribute blood supply to the hand.

images Sympathetic nerves exit the spinal cord along with the ventral roots of the second and third thoracic nerves, passing via the brachial plexus into the forearm and hand.

images The sympathetic nerve fibers innervate the blood vessel walls, controlling the tone of the vascular smooth muscle.

PATHOGENESIS

images Raynaud’s syndrome, a vasospastic disorder, is characterized by significant structural narrowing of the arterial lumen due to intimal hyperplasia. Vasospasm can occur from increased sympathetic tone in response to temperature, vibratory stimuli, and sometimes emotional stress, causing further ischemia and the clinical manifestation of color changes.

images Vasospasm can also be associated with pheochromocytoma, carcinoid syndrome, and cryoglobulinemia.

images Emboli can shower from a cardiac source (eg, chronic atrial fibrillation) or from microemboli in ulcerated, atherosclerotic plaques, either spontaneously or from iatrogenic cannulation of vessels during vascular procedures.

images Thrombosis may occur spontaneously from atherosclerotic disease or from repetitive blunt trauma to the vessels, as in hypothenar hammer syndrome.

images Low-flow states can occur in sepsis, malignant disease, hypercoagulable states (eg, polycythemia, lupus anticoagulant antibody), and after intra-arterial drug injections.

images These states predispose end organs to global thrombosis.

images Focal stenosis and segmental occlusion of vessels may result from intimal proliferation secondary to connective tissue disorders, atherosclerosis, and renal vascular disease.

images Vasospastic disorders may result from increased sympathetic tone.

images Vaso-occlusive disorders result in ischemia distal to the site of occlusion.

NATURAL HISTORY

images Clinical manifestations of vasospastic disorders range from episodic digital vasospasm and pain, to severe hand and digit ischemia, progressing to gangrene.

images The classic triphasic attack in Raynaud’s syndrome consists of sudden onset of digital pallor or blanching after cold exposure or emotional stress, followed by a period of cyanosis and then redness with rewarming, resulting in the classic white-blue-red sequence of color changes.1

images The typical Raynaud’s attack lasts for 15 to 45 minutes.

images Vaso-occlusive disorders follow a more predictable clinical course in that they usually result from fixed lesions that are progressive.

images Cold intolerance and vasomotor color changes in the hand develop, forcing patients to seek treatment.

PATIENT HISTORY AND PHYSICAL FINDINGS

images A complete history and physical examination must be done on each patient, focusing on evidence of connective tissue or cardiovascular disease.

images Does the patient describe paresthesias, pallor, cold intolerance, pain, digit ulceration?

images The entire upper extremity is examined for range of motion, skin color and turgor, capillary refill, radial and ulnar pulses, temperature, and presence of ulcerations.

images The distal fingertips and nails of each finger are examined closely.

images The radial and ulnar pulses are palpated and examined by Doppler probe if necessary.

images The palmar arch is assessed with the Doppler probe as well as the radial and ulnar digital arteries to each finger.

images Allen’s test is performed.

images The radial and ulnar arteries are occluded at the level of the wrist.

images The arterial flow is then re-established to the hand sequentially by releasing the radial and ulnar arteries, and capillary refill is assessed.

images This test evaluates the patency of arterial inflow to the hand through the radial and ulnar arteries.

images Any pulsatile masses are noted and evaluated.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Posteroanterior (PA), lateral, and oblique radiographs to evaluate bone architecture and the presence of any calcification in the radial and ulnar arteries, palmar arches, or digital arteries

images Doppler examination

images Echocardiogram to evaluate potential sources of emboli

images Digital photoplethysmography, which measures digital volume changes over time, can be used to differentiate vasospastic from vaso-occlusive disease.

images Segmental arterial pressure measurements

images Nielsen digital hypothermic challenge test14

images Ultrasonography7

images Angiography: remains the gold standard to evaluate blood flow to the hand

images MR angiography4

images Laboratory tests: complete blood cell count (CBC) with platelet count, coagulation studies, markers for collagen vascular diseases

DIFFERENTIAL DIAGNOSIS

images Raynaud’s disease

images Hypothenar hammer syndrome

images Malignancy

images Trauma

images Buerger disease (thromboangiitis obliterans): an inflammatory occlusive disease of the small and medium-sized vessels of the limbs

images Arteritis: a group of disorders characterized by acute or chronic inflammation in the walls of small, medium, and large arteries. Patients with these conditions often present with concurrent fever, malaise, weight loss, cutaneous lesions, and arthralgias.

images Diabetes

images Peripheral vascular disease, atherosclerosis

images Thoracic outlet syndrome

images Connective tissue disorders (eg, scleroderma, systemic lupus erythematosus, rheumatoid arthritis)

images Illicit drug use

images Vascular tumors

images Pseudoaneurysm

images Iatrogenic injury

NONOPERATIVE MANAGEMENT

images Pharmacologic therapy is the mainstay of treatment of vasospastic disorders of the hand.

images Avoidance of smoking and exposure to cold temperatures may control vasospastic episodes.

images Biofeedback

images Patients are trained to control certain bodily processes that occur involuntarily.

images Electrodes are attached to the skin of the patient and physiologic responses monitored.

images The biofeedback therapist then leads the patient through exercises that bring about desired physical changes.

images Occlusive dressings may be helpful both to protect areas from recurrent trauma and to promote healing of lesions.

images Calcium channel blockers, eg, nifedipine

images Pentoxifylline decreases blood viscosity and may result in relaxing vascular smooth muscle.

images Prostacyclins22

images Nitrates

images Local anesthetic blockade

images Botulinum toxin A21

images Thrombolytic therapy

SURGICAL MANAGEMENT

images The surgical management of vasospastic and vaso-occlusive diseases should proceed in a systematic fashion.

images Indications for operative management are progressive symptoms (eg, Raynaud’s syndrome, ulcers, pain, cold intolerance) despite optimal medical management and with angiographically defined occlusion of one or both inflow arteries (ie, radial, ulnar).

images Indications for a digital sympathectomy are progressive symptoms of Raynaud syndrome or ulcerations refractory to medical management with no evidence of major occlusion of the radial or ulnar arteries and with good visualization of three common digital arteries in the palm.

images Cold challenges are very painful for patients with scleroderma and systemic lupus erythematosus and are used on a case-by-case basis.

images The patient should be educated on the outcomes of the various procedures and realize the limitations of each one.

Preoperative Planning

images The preoperative history and physical examination are reviewed.

images The site of operative intervention is determined primarily by the preoperative imaging studies (eg, angiogram).

images If vascular grafting is indicated, the donor vessels are identified and marked.

Positioning

images The patient is placed in the supine position on the operating room table with the extremity on an appropriately padded hand table.

images An upper arm tourniquet is placed, because a bloodless field is essential.

images If a vein graft is anticipated, another extremity (usually a leg) is prepped and a proximal tourniquet applied.

Approach

images Usually, the hand surgeon must access proximal arterial inflow vessels when treating either vasospastic or vasoocclusive disorders of the hand.

images The brachial artery in the upper arm is approached via an incision on the medial aspect of the arm.

images The distal brachial artery and proximal radial and ulnar arteries are approached through a lazy S incision in the antecubital fossa.

images Care is taken to avoid making a straight line incision across the antecubital fossa.

images The radial and ulnar arteries in the forearm are approached through a longitudinal incision over the specific vessel.

images The palmar arches are accessed via Bruner incisions extending proximally from the proximal phalanges, using natural creases in the palm where possible, or through an inverted J-shaped incision in the palm.

images The digital arteries are approached through Bruner incisions on the palmar aspect of the finger or through a midlateral incision on the digit.

TECHNIQUES

FLATT DIGITAL SYMPATHECTOMY5

images  Flatt digital sympathectomy is used for patients with vasospastic disorders such as Raynaud phenomenon.

images  Proximal or cervical sympathectomy has largely fallen out of favor due to the high recurrence rates.

images  Peripheral sympathectomy has gained popularity since Pick17 identified sympathetic nerve fibers innervating the arteries from the wrist to the fingers.

images Sympathectomy is performed at the level of the digital arteries.

images  Make Bruner incisions in the distal palm and expose the digital arteries.

images  Disrupt all connections between the digital nerves and digital arteries.

images  Strip the adventitia from the digital arteries over a distance of 0.5 to 2.0 cm using the operating microscope (TECH FIG 1A,B).

images This must be performed very carefully to avoid damaging the digital arteries themselves.

images  In cases of more widespread vasospasm, when more radical digital sympathectomy is required, strip the adventitia from the distal radial and ulnar arteries, the superficial palmar arch, and the common digital arteries in the palm8,9,15 (TECH FIG 1C,D).

images

TECH FIG 1  A,B. View through the operating microscope before (A) and after (B) removal of the adventitia from a common digital artery. C,D. Radical or extensive digital sympathectomy before (C) and after (D) stripping the adventitia from the distal ulnar artery, superficial palmar arch, and common digital arteries to the index–middle, middle–ring, and ring–small finger web spaces.

LERICHE SYMPATHECTOMY 12

images  If adequate collateral flow is present, consider excision of a segment of thrombosed or occluded artery.12

images  This is thought to reduce the sympathetic discharge from the diseased artery that is producing vasospasm in the more distal vessels.

images  It also occasionally is used to treat a thrombosed or occluded ulnar artery in hypothenar hammer syndrome.

MICROSURGICAL REVASCULARIZATION

images  Reconstruction of a thrombosed or occluded artery is considered if:

images A discrete segment of artery can be resected and bypassed.

images Adequate arterial inflow and patent distal arteries with adequate distal “run-off” are present.

images  Resect the arterial segment and measure the defect.

images  Reverse vein grafts (eg, cephalic, saphenous) or arterial grafts (eg, deep inferior epigastric artery, lateral circumflex artery, thoracodorsal artery) are harvested in the standard fashion.

images  Draw an axial line down the length of the vessel to be harvested while it is still in situ.

images This helps prevent inadvertent “twisting” of the graft during the anastomoses.

images  Perform standard microsurgical anastomoses using 9-0 or 10-0 nylon sutures and the operating microscope between the distal radial or ulnar arteries and the deep or superficial palmar arches respectively, or directly to one or more common digital arteries (TECH FIG 2).

images  An end-to-side anastomosis of the graft to the inflow artery is preferable to maximize any remaining circulation to the hand, but end-to-end anastomoses are technically easier.

images  The distal anastomosis usually is end-to-end to the superficial or deep palmar arches or end-to-side to the common digital arteries.

images  After the anastomoses have been completed, the tourniquet is deflated, and vascular inflow through the other artery is occluded by manual compression for a few minutes to maximize flow across the anastomoses.

images  Restoration of arterial flow into the hand is assessed either by using a pencil Doppler probe or by performing an Acland “adventitial strip test” distal to the distal anastomosis.

images

TECH FIG 2  A. Microsurgical revascularization for thrombosis or occlusive disease of the distal ulnar artery and superficial palmar arch, using an interposition vein graft from the ulnar artery to the common digital arteries. B. Microvascular revascularization for thrombosis or occlusive disease of the distal radial artery and deep palmar arch, using an interposition vein graft from the radial artery to the princeps pollicis artery.

EMBOLECTOMY

images  An acute embolus is treated by immediate heparinization to prevent propagation of the embolus more distally into the digits.

images  Small Fogarty embolectomy catheters may be used selectively at the arm, elbow, forearm, and wrist levels, but use of embolectomy catheters in the hand and digits is difficult and can itself lead to vascular injury.

images  After identification of the segment involved by the embolus, control the affected artery both proximal and distal to the embolus.

images  Make a longitudinal arteriotomy proximally to access the vessel lumen.

images A side branch may be chosen if available.

images  Insert the Fogarty catheter into the artery, and pass it down the lumen beyond the area of occlusion; then inflate the balloon.

images  Gently withdraw the catheter to retrieve any thrombus.

images This is repeated until the lumen is completely cleared of the embolus, as demonstrated by improved backbleeding from the distal vessel.

images  Suture the arteriotomy and release arterial inflow.

images  Assess the restoration of arterial flow into the hand either by using a pencil Doppler probe on the artery more distally or by performing an Acland “adventitial strip test” distal to the site of embolism.

ARTERIALIZATION OF THE VENOUS SYSTEM

images  Choose a suitable vein on the dorsum of the hand, that is, one that will lie in a straight line following anastomosis to the radial or ulnar artery near the palmar wrist.16

images  Mobilize the vein and ligate the multiple side branches of the vein with small hemoclips to maximize flow to the fingers.

images  Perform valvulotomies in the vein to prevent valvular obstruction.

images  Ligate the vein proximally and perform an end-to-side microsurgical anastomosis between the vein and the radial or ulnar artery at the wrist.

images  After the anastomosis has been performed, assess arterial flow through the distal vein.

images Any remaining obstruction due to a valve should be relieved by an open valvulotomy and excision of the valve leaflets, followed by microsurgical closure of the vein.

images  Postoperative monitoring is performed using a pencil Doppler probe over the distal arterialized vein to the fingers.

images

POSTOPERATIVE CARE

images The hand is immobilized in a lightweight splint to protect the operative site, with care taken to avoid any pressure on the underlying anastomoses or vulnerable mobilized arteries.

images The fingertips are observed for color and capillary refill, temperature using small temperature probes or oxygen saturation using a pulse oximeter.

images Microvascular reconstruction with interposition grafts can be monitored using a pencil Doppler probe.

images Relative anticoagulation can be achieved using a continuous infusion of dextran 40 or low-dose aspirin.

OUTCOMES

images Calcium channel blockers have been shown to be moderately effective in patients with Raynaud’s phenomenon, with 35% reporting improvement in severity of their symptoms.19

images The results of sympathectomy remain variable, although surgeons have reported improvements in pain, ulcer healing, cold intolerance, and quality of life.8,11,18,20

images Long-term patency rates for vascular bypass grafting secondary to occlusive disease have been reported to range between 53% and 94%.2,8,10,13

images Combining sympathectomy with arterial reconstruction may offer improved outcomes versus sympathectomy alone.6

COMPLICATIONS

images Bleeding and hematoma

images Infection

images Thrombosis of the interposition graft

images Progression of the underlying systemic disease

REFERENCES

1.     Allen E. Raynaud’s disease: A review of minimal requisites for diagnosis. Am J Med Sci 1932:83:187–200.

2.     Barral X, Favre JP, Gournier JP, et al. Late results of palmar arch bypass in the treatment of digital trophic disorders. Ann Vasc Surg 1992:6:418–424.

3.     Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 1961:113:409–424.

4.     Dalinka MK, Meyer S, Kricun ME, et al. Magnetic resonance imaging of the wrist. Hand Clin 1991:7:87–98.

5.     Flatt AE. Digital artery sympathectomy. J Hand Surg Am 1980:5: 550–556.

6.     Given KS, Puckett CL, Klienert HE. Ulnar artery thrombosis. Plast Reconstr Surg 1978:61:405–411.

7.     Hutchinson DT. Color duplex imaging: Applications to upper extremity and microvascular surgery. Hand Clin 1993:9:47–51.

8.     Jones NF. Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis. J Hand Surg Am 1991:16: 1074–1083.

9.     Jones NF. Ischemia of the hand in systemic disease: the potential role of microsurgical revascularization and digital sympathectomy. Clin Plast Surg 1989:16:547–556.

10. Koman LA, Ruch DS, Aldridge M, et al. Arterial reconstruction in the ischemic hand and wrist: effects on microvascular physiology and health-related quality of life. J Hand Surg Am 1998:23:773–782.

11. Koman LA, Smith BP, Pollack FE. The microcirculatory effect of peripheral sympathectomy. J Hand Surg Am 1999:20:709–717.

12. Leriche R, Fontaine R, Dupertius SM. Arterectomy with follow-up studies on 78 operations. Surg Gynecol Obstet 1937:64:149–155.

13. McCarthy WJ, Flinn WR, Yao JST, et al. Result of bypass grafting for upper limb ischemia. J Vasc Surg 1986:3:741–746.

14. Nielsen SL, Lassen NA. Measurement of digital blood pressure after local cooling. J Appl Physiol 1977:43:907–910.

15. O’Brien BM, Kumar PA, Mellow CG, et al. Radical microarteriolysis in the treatment of vasospastic disorders of the hand, especially scleroderma. J Hand Surg Br 1992:17:447–452.

16. Pederson WC, Woodward C, Hermansdorfer J. Arterialization of the venous system for the treatment of end-stage ischemia of the upper extremity. J Reconstr Microsurg 1996:12:414.

17. Pick J. The Autonomic Nervous System. Philadelphia JB Lippincott, 1970.

18. Ruch DS, Koman LA, Smith TL. Chronic vascular disorders of the upper extremity. J Am Soc Surg Hand 2001:1:73–80.

19. Thompson A, Shea B, Welch V, et al. Calcium channel blockers for Raynaud’s phenomenon in systemic sclerosis. Arthritis Rheum 2001:44:1841–1847.

20. Tomaino MW, Goitz RJ, Medsger TA. Surgery for ischemic pain and Raynaud’s phenomenon in scleroderma: a description of treatment protocol and evaluation of results. Microsurgery 2001:21:75–79.

21. Van Beek AL, Lim PK, Gear AJL, et al. Management of vasospastic disorders with botulinum toxin A. Plast Reconstr Surg 2007:119: 217–226.

22. Wigley F, Wise R, Seibold J, et al. Intravenous iloprost infusion in patients with Raynaud’s phenomenon secondary to systemic sclerosis. Ann Intern Med 1994:120:199–206.



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